The Willow Tree Surgery

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as requires improvement. The service was in breach of legal regulation in relation to providing safe care and treatment.

Since the last assessment, the practice has made sufficient improvements and is no longer in breach of regulation 12 safe care and treatment. The overall rating for this key question has changed to good.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the comprehensive assessment in February 2025, the provider could not demonstrate how learning from incidents and complaints was used to improve service delivery. At this assessment we found that the provider had improved processes for recording, investigating and learning from incidents and complaints. The provider had processes for staff to report incidents and safety events. There was a system to record and investigate complaints, and there was evidence that when things went wrong, staff apologised and gave people support. We saw evidence of significant event analyses that were thoroughly documented detailing actions to reduce the risk of recurrence. We saw evidence of meeting minutes documenting learning outcomes that had been shared with staff. Meeting minutes were structured with incidents and complaints as standing agenda items. For example, an incident in January 2026 involving a power cut to the practice was thoroughly documented with clear agreed actions including updating the business continuity plan and reviewing cold chain procedures for vaccine fridges. The incident was documented for discussion and learning at the next practice meeting.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At the comprehensive assessment in February 2025, we found that oxygen tubing was missing from the emergency bag. At this assessment we found the appropriate emergency equipment was available including oxygen tubing, and there was evidence that the equipment was regularly checked.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

At the comprehensive assessment in February 2025, we found that the provider had not risk assessed the patient waiting area as it was partially out of sight of the reception staff leaving a risk of patient deterioration without staff being aware. At this assessment we found that the provider had improved CCTV coverage to include the waiting area in addition to the carpark and entrance to the practice. A light outside the entrance door was in working order to ensure people could approach the practice safely in the evening.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At the comprehensive assessment in February 2025, the provider could not evidence training records for all staff employed and staff immunisation records were incomplete. In addition, the provider could not show evidence that they had sought assurance from the Primary Care Network (PCN) that Additional Roles Reimbursement Scheme (ARRS) staff had the necessary checks and training to carry out their roles safely and effectively. At this assessment we found these shortfalls had been rectified. There were a range of clinical and non-clinical roles within the practice. We checked 6 staff records and found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed, and staff immunisation records were up to date. Assurance had been sought that ARRS staff had the necessary checks and training.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

At the comprehensive assessment in February 2025, we found concerns with the monitoring of people’s health conditions, out of date Patient Group Directions (PGDs), no Patient Specific Directions (PSDs), non-compliance with medicine safety alerts and incomplete medicine reviews.

At this assessment we found some improvement. For example, PGDs (legal frameworks in the UK allowing registered health professionals e.g. nurses and pharmacists, to supply and administer specific medicines to pre-defined patient groups without a doctor's prescription) were up to date and signed by the doctor and the staff member administering them. PSDs (a written, signed instruction from a doctor authorizing the administration or supply of a medicine to a specifically named patient, or a list of named patients) were in place for the HCA to administer vaccines safely. We found the recording of medicine reviews had improved and reviews were comprehensively documented.

Our clinical searches identified some concerns similar to the issues identified at the comprehensive assessment in February 2025. However, overall monitoring had improved with many fewer patients identified for follow-up. For example:

There were 315 patients on a medicine to treat high blood pressure, heart failure and kidney disease. From these patients the searches identified 13 who had potentially not had the required monitoring prior to issuing a prescription. We sampled 5 of the 13 patients and found that 3 patients had been prescribed the medicine without sight of the required blood tests.

There were 115 patients with hypothyroidism (low activity of the thyroid gland). From these patients the searches identified 5 who had potentially not had the required monitoring prior to issuing a prescription. We sampled all 5 patients and found that 4 patients had been prescribed the medicine without sight of the required blood tests.

Three out of 5 patients sampled of childbearing age prescribed a medicine to treat nerve pain, epilepsy and generalised anxiety disorder had no documented pregnancy prevention plan in the record in line with an MHRA alert from April 2022 to mitigate risks of birth defects.

Following the clinical searches the provider took action to mitigate the risks. They provided evidence that each patient had been contacted and appropriate action taken. The provider assured us that moving forward they would regularly run searches on the computer system to mitigate clinical risks.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen safely.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed the practice was prescribing in line with national averages for all prescribing indicators.